Introduction

If you have -- voluntarily or involuntarily -- spent time watching Sesame Street on television, you probably remember hearing "one of these things is not like the others." It's a catchy little tune used to teach children to categorize, and it was going through my head at the International AIDS Conference in Vienna last July. It started during the opening plenary, as Yves Souteyrand, a health economist from the World Health Organization (WHO), described the populations most at risk for HIV infection in various countries and regions.

Souteyrand said that, globally, men who have sex with men (MSM) have 19.3 times greater risk of being infected with HIV than people in the general population, and that their risk is arguably greatest in the more than 80 countries in which homosexual activity is criminalized.

He noted that laws in 40% of countries currently limit access to HIV services for injection drug users (IDUs). Souteyrand highlighted Ukraine's progress in scaling up evidence-based prevention and treatment interventions for IDUs: After steadily climbing for a decade, new HIV infections in that country are now starting to decline. The HIV prevalence among Ukranian IDUs, estimated at 30% in 2004, is now down to about 11%. Good news!

But Souteyrand concluded his talk without presenting data on the impact that criminalization and marginalization have on sex workers and their HIV risk. He omitted this group even though his WHO data showed that sex workers account for an equal or higher percentage of new infections in sub-Saharan Africa (home to more than two-thirds of all people living with HIV), compared with the other two populations he had been discussing. Wait a minute!

Upon reflection, I realized that this omission is actually common in discussions about the causal links between criminalization, marginalization and increased HIV transmission. We talk a lot about the effects of this dynamic on men who have sex with men, injection drug users and people living with HIV -- as we certainly should -- but not about sex workers. Why is this group not like the others?

What Do the Data Say?

Comparative discussions are difficult given the frustrating dearth of accurate data on the impact of the AIDS epidemic on each of these populations in various regions. The Global HIV Prevention Progress Report Card 2010 notes that, of the 169 countries reporting epidemiological data to the Joint United Nations Programme on HIV/AIDS (UNAIDS) in 2008, only 38% had survey-based estimates of HIV prevalence among female sex workers, 31% had estimates on MSM, and only 26% had data on prevalence among IDUs.

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The data that do exist are spotty and incomplete, especially with regard to MSM -- a category not even recognized in many regions. Mozambique, for example, estimates that sex work contributed directly or indirectly (via clients to their regular partners) to 19% of new HIV infections in 2007. They attribute 3% of new cases in the country to injection drug use and 5% to sex between men. In Uganda, sex work is cited as accounting for 10% of new infections, while MSM and IDUs together accounted for less than 1% -- figures that are neither credible nor surprising in light of the Ugandan government's tendency to deny the presence of homosexuality and injection drug use in that country.

The Kenyan government, by contrast, is now gathering much more accurate data and preparing to roll out its first HIV prevention campaign targeted to MSM. A national survey recently conducted by the Kenya Medical Research Institute reported that 15% of all new HIV infections were occurring among MSM, and 14% among sex workers and their clients.

The U.S. Centers for Disease Control and Prevention (CDC) now describes several major U.S. cities as having "generalized" HIV epidemics that are primarily associated with poverty and affect populations outside of the major at-risk groups.

The CDC confirms that the majority of new infections in the U.S. are still occurring among MSM, and estimates that injection drug use accounts for 12% of the country's new HIV infections each year. But the agency provides no parallel estimate of the number occurring among sex workers. This gap is surprising, given that the CDC has funded and participated in sophisticated research to assess the rate of new infections among sex workers in many other parts of the world.

Scientifically Sound but Politically Unpalatable

The worldwide lack of accurate reporting on real HIV incidence among the most marginalized and at-risk groups is connected to the paltry funding set aside for HIV prevention. According to UNAIDS, 4.7% of all global HIV prevention spending in 2008 was allocated to programs targeting IDUs, 3.3% for MSM programs and 1.8% for programs reaching sex workers.

These shockingly low funding levels also correlate with the fact that all three populations are characterized by behavior that is criminalized, one way or another, in most countries. The Global HIV Prevention Working Group notes that "sex work is illegal in at least 110 countries, consensual sex between adults of the same sex is criminalized in more than 80 countries, and substitution therapy with methadone and buprenorphine is allowed in only 52 and 32 countries, respectively."

This political dynamic has far-reaching effects: Criminalization leads to marginalization and invisibility; invisibility masks the need for adequately funded, effective services. As the late gay African American writer James Baldwin once observed, "you cannot fix what you will not face." With regard to governments, this translates into, "you do not have to fix what you do not face."

Countries routinely use this approach to avoid uptake of public health strategies that are, in the words of Paula Akugizibwe of the AIDS and Rights Alliance for Southern Africa, "scientifically sound but politically unpalatable." So let's look at how advocates for IDUs and MSM have dealt with this neglect, and see if it tells us anything about why sex workers have yet to command the attention and broad-based public support among HIV/AIDS and human rights advocates that their evident risk level warrants.

PEPFAR and Needle Exchange

The President's Emergency Plan for AIDS Relief (PEPFAR), a massive funding bill created to implement the 2003 Global AIDS Act, was first funded in 2004 and reauthorized by Congress in 2008 with a significant funding increase.

While it represents a step forward in terms of overall investment in HIV/AIDS efforts, PEPFAR has some major limitations. For example, it failed to allow support for harm reduction programs, including syringe exchange, which has been shown to help IDUs limit their risk of acquiring or passing on HIV and other blood-borne diseases. Instead, PEPFAR funding could only be used for work with IDUs already living with HIV. Until December 2009, the U.S. government refused to fund harm reduction programs, either domestically or internationally, that involved syringe exchange.

In 1985, the first evidence of the effectiveness of needle exchange was published in Amsterdam. The following year, an HIV prevention pioneer named Jon Parker started exchanging used needles for clean ones in the U.S., getting arrested and inspiring activists across the country -- and organizations like San Francisco AIDS Foundation -- to follow his example.

Four years later, use of U.S. federal funds for needle exchange services was officially banned. One stipulation of the 1989 federal ban was that it could not be lifted unless the President or the U.S. Surgeon General could certify that needle exchange lowered HIV transmission rates without increasing drug use. But the National Institutes of Health was explicitly forbidden to evaluate needle exchange programs, and researchers interested in conducting such evaluations were told that these proposals could not be considered for federal funding. No evidence generated, no way to certify the effect, no way to lift the ban!

Working with activists, dedicated epidemiologists (mostly supported by their academic institutions) persisted in gathering, analyzing and publishing evidence that needle exchange works. A decade -- and uncounted lives -- later, the U.S. Secretary of Health and Human Services reported that solid scientific evidence showed that the two conditions required to lift the ban had been met. In 2000, the Surgeon General formally concurred with this finding. Yet the ban remained in place.

Since 2000, clean needles have become more widely available in the U.S. through a variety of mechanisms, including prescription-free pharmacy access, state and local health departments' needle exchange programs -- since states are empowered to make their own policies on this issue -- and, in some areas, "decriminalized" exchanges which are technically illegal but tolerated by law enforcement.

By this time, however, the U.S. was the only country in the world that explicitly banned the use of federal funds for needle exchange services. Approximately five million injection drug users live in 13 PEPFAR-supported countries across Eastern Europe, Asia, and Africa. So U.S. policy was withholding HIV prevention tools from domestic IDUs and those in PEPFAR-recipient countries.

After long years of HIV-prevention and harm reduction advocacy -- including expert testimony before Congress on the effectiveness of syringe exchange -- President Obama lifted the domestic needle exchange funding ban on December 16, 2009. Six months later, the U.S. Department of Health and Human Services (DHHS) issued new policy guidance for PEPFAR that allows funding for needle exchange programs and medication-assisted therapy (treating opioid dependence with substitution drugs, including methadone and buprenorphine).

The guidelines stipulate that these programs can be funded only in areas where they comply with local laws and regulations, but the U.S. government is no longer refusing to support these urgently needed strategies. As former International AIDS Society President Julio Montaner declared in Vienna, "there is no successful intervention for HIV that does not include a comprehensive prevention package for IDUs. That is non-negotiable."

The Vienna Declaration

In the summer of 2010, advocacy groups worldwide began circulating the Vienna Declaration, a statement "seeking to improve community health and safety by calling for the incorporation of scientific evidence into illicit drug policies."

Spearheaded by the International AIDS Society, the International Centre for Science in Drug Policy and the British Columbia Centre for Excellence in HIV/AIDS, the declaration was formally launched at the International AIDS Conference in Vienna. It has been endorsed by more than 18,000 people to date, including such influential advocates as Michel Kazatchkine, Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria; former United Nations Special Envoy on AIDS Stephen Lewis; and several Nobel laureates in biochemistry, economics, medicine, virology and other fields.

Framed in the language of human rights, the declaration explicitly calls for governments to reduce drug-related harm by supporting needle exchange and opiate substitution programs rather than harsh criminalization policies. To read the declaration, visit www.viennadeclaration.com.

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